Nursing Elites

1. What are the primary causes of respiratory acidosis?

• A. Hypoventilation and lung disease
• B. Hyperventilation and pneumonia
• C. Increased oxygen saturation and tachypnea
• D. Dehydration and hypoxia

Correct answer: A

Rationale: The correct answer is A: Hypoventilation and lung disease. Respiratory acidosis occurs when there is an accumulation of CO2 in the body due to inadequate ventilation. Hypoventilation, which reduces the elimination of CO2, and lung diseases that impair gas exchange are the primary causes. Choice B is incorrect because hyperventilation, not hypoventilation, leads to respiratory alkalosis, not acidosis. Choice C is incorrect because increased oxygen saturation and tachypnea do not directly cause respiratory acidosis. Choice D is incorrect as dehydration and hypoxia do not typically lead to respiratory acidosis.

2. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

3. A nurse is contributing to the plan of care for a client following a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include?

• A. Administer antibiotics
• B. Irrigate the bladder using sterile technique
• C. Avoid irrigating the bladder
• D. Insert a urinary catheter

Correct answer: B

Rationale: Irrigating the bladder using sterile technique is crucial in the care of a client following a transurethral resection of the prostate (TURP). This intervention helps prevent infection and maintains patency of the urinary catheter, promoting healing. Administering antibiotics (Choice A) may be necessary if there is an infection present, but it is not a routine intervention following TURP. Avoiding bladder irrigation (Choice C) is not recommended as it can lead to clot retention and other complications. Inserting a urinary catheter (Choice D) is usually already done during the TURP procedure and is not a postoperative intervention.

4. A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions should the nurse take?

• A. Wear a gown within 3 feet of the client
• B. Maintain a distance of 6 feet from the client
• C. Wear a surgical mask within 3 feet of the client
• D. Remove gloves before leaving the room

Correct answer: C

Rationale: The correct action for the nurse to take when maintaining droplet precautions for a client with meningitis is to wear a surgical mask within 3 feet of the client. This is essential to prevent the transmission of meningitis via respiratory droplets. Choice A is incorrect because wearing a gown is not specifically required for droplet precautions. Choice B suggests maintaining a distance of 6 feet, which is more applicable to airborne precautions, not droplet precautions. Choice D is incorrect as gloves should be removed and disposed of properly, but it is not related to droplet precautions specifically.

5. What should a healthcare professional prioritize when managing a client with delirium?

• A. Administering sedative medication
• B. Providing a low-stimulation environment
• C. Identifying the underlying cause of the delirium
• D. Controlling behavioral symptoms with medication

Correct answer: C

Rationale: When managing a client with delirium, the priority should be to identify the underlying cause of the delirium. Delirium can result from various triggers such as infections, medication side effects, or metabolic imbalances. By determining the root cause, healthcare professionals can provide targeted treatment and improve outcomes. Administering sedative medication (Choice A) could exacerbate delirium as these drugs can worsen confusion. While providing a low-stimulation environment (Choice B) is beneficial, it is not as critical as identifying the cause. Controlling behavioral symptoms with medication (Choice D) should only be considered after identifying and addressing the underlying cause of delirium.

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